Summary:
Summary Statement of Deficiencies D5787 TEST RECORDS CFR(s): 493.1283(a) (a) The laboratory must maintain an information or record system that includes the following: (a)(1) The positive identification of the specimen. (a)(2) The date and time of specimen receipt into the laboratory. (a)(3) The condition and disposition of specimens that do not meet the laboratory's criteria for specimen acceptability. (a)(4) The records and dates of all specimen testing, including the identity of the personnel who performed the test(s). This STANDARD is not met as evidenced by: Based on lack of patient test records for Mohs testing, review of the Mohs log and interview with the facility personnel, the laboratory failed to maintain a copy of the Mohs map for one out of five patient records reviewed. Findings include: 1. The laboratory performs laboratory testing in conjunction with Mohs under the subspecialty of Histopathology, with an annual reported test volume of 84. 2. The laboratory utilizes an Electronic Medical Record (EMR) system to maintain Mohs test results, including the Mohs map. 3. Two out of three patient test records reviewed during the survey were missing the Mohs map. The maps were not scanned into the patients' EMR. (Case # OLM25-0020- performed on 2/14/25 and Case # OLM25- 0056 performed on 5/9/25). 4. The facility personnel interviewed on 9/15/25 at 9:30 AM confirmed the laboratory failed to maintain a copy of the Mohs map for the cases indicated above. Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 1 --